Provider Demographics
NPI:1750329306
Name:TLC FOR WOMEN
Entity type:Organization
Organization Name:TLC FOR WOMEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:770-995-9100
Mailing Address - Street 1:2069 TERON TRCE
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1665
Mailing Address - Country:US
Mailing Address - Phone:770-995-9100
Mailing Address - Fax:770-822-9444
Practice Address - Street 1:555 OLD NORCROSS RD
Practice Address - Street 2:SUITE 250
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8716
Practice Address - Country:US
Practice Address - Phone:770-995-9100
Practice Address - Fax:770-822-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043436207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4804710OtherCIGNA
GA5554055OtherAETNA
GA0013191OtherBCBS
GA309499OtherWELLCARE
GA000750362BMedicaid
GAP00130132OtherRR MEDICARE
GAF73020Medicare UPIN
GA4804710OtherCIGNA
GA5554055OtherAETNA